Wednesday, September 24, 2014

The Laerdal Japanese Simulation Users Network almost doubled in size from last year. One hundred thirty people from around Japan attended last year in Osaka. This year in Tokyo, 200 people attended. Some of my questions about how simulation translates to an Eastern culture were partially answered by this SUN meeting. I was invited to participate as a keynote, to present the results of the National Council of State Boards of Nursing (NCSBN) National Simulation Study. Very unexpectedly, the question I thought that would be asked in Chicago at the unveiling of the NCSBN results was not, but it was the first questions asked here after I finished my presentation, if simulation was not better, then why do it? I think it was a physician who asked…this led to a discussion of rapidly deteriorating clinical opportunities for students and rising patient complexity. Japanese nursing faculty may take care of between 5-20 students a piece at times in Japan. I cannot even imagine this myself; a 1:10 ratio is bad enough.

This is a culture that has valued rote memorization. Simulation is an outside the box teaching modality, for them, but the Japanese faculty and attendees were very enthusiastic and seemed to be outliers themselves…more animated and outgoing than I was anticipating.

Simulations, on average, seems to be run for about ten minutes and then debriefed for about 20 minutes, as a norm in Japan, at this time. Simulations tend to be one profession only. The loss of face in front of others and other disciplines in a hierarchical culture is a huge issue, so western style inter-professional education is not occurring very often, at least as we know it. Overlaid on the loss of face issue is the same scheduling issue we have in the US, between different programs and courses of study.

Because of the loss of face issue, I wonder if adopting expert modeling as a rule of thumb or a group the fist time, might help to mitigate this issue. I would do a modeling scenario with all appropriate players, then have participants do it debrief, then do a similar but different transfer scenario, so that learners could try their kills in a similar situation but enough of a difference that they could build some competence, but with face saving scaffolding.

The debriefing session I attended seemed to indicate that the facilitator provides feedback on the learner performance using the gather, analyze, synthesize (GAS) model. However, the GREAT model, developed or used by Dr. Harry Owens at Flinders University was also discussed. As was Goal Oriented Debriefing the (god model), something I had not heard of before. The Japanese culture at this time seems to favor a more teacher centered style of debriefing rather than learner centered. This course faculty member used the clicker system and did some self-reflection questions with his audience. People did speak in this session on occasion, but not much. The clicker question results indicated that attendees were not confident in their debriefing skills and that they did not notice a large change in behavior of their students post simulation. It looks like much work to do still. I suspect they are not using a lot of simulation and students are still figuring how to learn in simulation.

I got to try out the QCPR system that gives fabulous feedback while performing practice CPR…oh my gosh! What fun, how tiring, this is the first time I have practiced on a feedback manikin with the 2010 American Heart Association guidelines programed in, compressing at 51 mm rather than 48 mm is tough! Note to self, get CPR renewed. The ironic thing is, the next big CPR study we are getting ready to do includes learning Japanese phrases…here I am in Japan, with my very few Japanese phrases, doing CPR!

The Japanese culture values face, so admitting that one has made a mistake alone is almost unheard of, CRM as we know it will not work, as it is not ok to question anything a higher up is doing. Currently, there is almost no interprofessional team training, partly because if this problem…and all of ours in the US, trying to mesh schedules, etc. I tried an exercise to demonstrate simulation as a teacher for psych-social issues, I am thinking it did not work well.

I think I learned more than I shared, across my many talks and the Sim Health conference. Happy to share with you also.